CME J R Coll Physicians Edinb 2010; 40:32834

doi:10.4997/JRCPE.2010.417
2010 Royal College of Physicians of Edinburgh

Cannabis and the lung

1
PT Reid, 2J Macleod, 3JR Robertson
1
Consultant Respiratory Physician, Western General Hospital, Edinburgh; 2Professor in Clinical Epidemiology and Primary Care, University
of Bristol; 3General Practitioner, Muirhouse Medical Group, Edinburgh, UK

ABSTRACT The use of cannabis is embedded within many societies, mostly used Correspondence to PT Reid,
by the young and widely perceived to be safe. Increasing concern regarding the Respiratory Medicine, Western
potential for cannabis to cause mental health effects has dominated cannabis General Hospital, Crewe Road,
research and the potential adverse respiratory effects have received relatively Edinburgh EH4 2XU, UK
little attention. Studies on cannabis are challenging and subject to confounding by
tel. +44 (0)131 537 1768
concomitant use of tobacco and other social factors, and while many of the e-mail peter.reid@luht.scot.nhs.uk
studies referred to in this review are beset by the difficulties inherent in
undertaking epidemiological research of the effects of cannabis, there is an
emerging concern among many chest physicians who would suggest that habitual
smoking of cannabis may contribute to the development of chronic obstructive
pulmonary disease, pneumothorax and respiratory infections, including
tuberculosis. Special attention should be given to the risk of lung cancer,
particularly as biological plausibility may precede epidemiology.
Keywords Cannabis, lung cancer, pneumothorax, smoking, tuberculosis
Declaration of Interests Dr Reid, Dr Robertson and Professor Macleod
hold a grant from the Chief Scientist Office, Scotland, to investigate the
respiratory effects of regular cannabis use in a primary care population.
education

Background cannabis use. Recent information from the 2007/2008

Cannabis sativa is a herbaceous plant that shares the
botanical group Cannabaceae with the hop plant. The
stems of the plant can be retted a process of steeping
or watering to form hemp, which has been widely used
in rope making and other fabrics. The plant also contains
a variety of cannabinoids, including delta-9-tetra-
hydrocannabinol (D9THC), which acts as the principal
psychoactive component contributing to the activity of
cannabis as a psychotropic drug. D9THC is understood
to bind to cannabinoid receptors in the brain which
normally bind the natural neurotransmitter anandamide
(ananda meaning bliss in Sanskrit).
The cannabis plant grows easily and quickly in a range of
climatic and soil conditions, including both tropical and
temperate regions, and is increasingly cultivated indoors
using hydroponic techniques which exploit the use of
nutrient-rich liquids in place of soil. These properties
mean that cannabis may be grown in almost every country
worldwide so it is perhaps not surprising that cannabis
has emerged as the worlds most commonly used illegal
drug.1 The most recent survey by the European Drugs
Monitoring Centre suggests, as a conservative estimate,
that cannabis has been used at least once (lifetime
prevalence) by more than 70 million European adults, with
around 23 million using cannabis in the past year.2
The situation in the UK is little different. Although
recreational use of cannabis was rare before the 1960s,3,4
since then the UK has witnessed a dramatic increase in
British Crime Survey,5 focusing on household samples of
people aged 1659 years living in England and Wales,
suggests that cannabis was by far the most commonly
used illegal drug, with 7.4% of this population reporting
cannabis use in the preceding year. The use of cannabis
is particularly prevalent in the young, with the highest
levels of use generally being reported among the 15- to
24-year-old age group;2 for example, in Scotland cannabis
use has been reported in 13% of 15-year-old boys and
10% of 15-year-old girls.6
Partly as a response to the increased use of cannabis in
recent years and the associated increase in the prison
population sentenced for cannabis-related crimes in the
UK, the Home Secretary encouraged the Advisory
Council to consider rescheduling this drug under the
Misuse of Drugs Act.The subsequent reclassification into
class C rather than class B was intended to allow the
downgrading of sentencing tariffs and reduce the prison
problems; however, national and international political
pressures led to a reversal of this decision within a few
years.7,8 Further increases in the use of cannabis are
anticipated over the next decade.1
When used as a drug, cannabis is most commonly
smoked; however, the form and method of smoking vary
widely. For example, in Scotland, the majority of users
smoke cannabis resin (a sappy substance secreted from
the plant during the flowering phase supplied as a green
resinous product, colloquially known as soap bar),
which is cut with tobacco and smoked as a handmade

328

unfiltered cigarette known as a joint.9 The joint is often
single skinned and unfiltered, although a roach (usually a
small piece of rolled-up cardboard) may be employed to
allow the user to hold the joint at a reasonable temperature.
Cannabis resin, also known as hash, is smoked widely
throughout Europe, but in the Americas the flowering tops
and leaves of the plant (marijuana) predominate and the use
of cannabis resin is limited.1 Cannabis may also be smoked
through a modified water pipe known as a bong which
draws the cannabis through water cooling the inhaled
vapour. This method, while used in the UK and Europe,
is perhaps more common in Australasia.1
The widespread use of cannabis also appears to have been
accompanied by an increase in the use of stronger skunk
cannabis or sinsemilla (literally from the Spanish without
seed). The potency of cannabis is, at present, determined
by its content of D9THC, the primary active constituent.
The greatest concentrations of D9THC are harvested
from the unfertilised female plant; hence, sinsemilla
provides the highest concentration. This form of cannabis
is most easily cultivated indoors and attracts the use of
colourful names such as super-skunk, AK-47 and northern smoked at least ten joints per week or the equivalent of
lights, to name but a few. Whereas the concentration of
D9THC may be around 24% in herbal cannabis, the
concentration in sinsemilla (skunk) may approach 10% or
15%. There is concern, particularly from police data on
drug seizures, that the availability of skunk has increased
dramatically in the UK within the past decade.10
The majority of cannabis research has focused on the
psychiatric consequences and only limited attention has
been given to the potential of cannabis to impact on the
lung. The small number of studies that have examined
the potential for cannabis to affect lung health have been
undertaken in North America, Australia, New Zealand
and North Africa; the remaining information is drawn
from selected case reports and personal clinical
experience and these have contributed to an emerging
concern that cannabis may be linked to the development
of chronic obstructive pulmonary disease (COPD), the
presentation of pneumothorax, a predisposition to
respiratory infections and, perhaps most worryingly, the
development of lung cancer. Such research is particularly
important when one considers that the majority of
cannabis smokers are young and have yet to complete
lung growth, which may make them particularly
susceptible to any potential adverse effects.
Cannabis and Chronic Obstructive
Pulmonary Disease
Chronic obstructive pulmonary disease has assumed
major importance in the world health agenda. Current
estimates suggest that the condition has a prevalence of
around 1% in the general population, but this is probably
higher in older age groups.11 T
he condition is characterised
by an accelerated loss of lung function and life-long
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Cannabis and the lung
disability. However, the increasing prevalence and
potential impact of the disease may be most clearly seen
in population mortality tables where COPD is predicted
to become the worlds third leading cause of mortality
by 2030.12
The definition of COPD embraces the concept that the
condition may be invoked by an abnormal inflammatory
response of the lung to noxious particles and gases.13 In
this regard, the most important aetiological factor is
tobacco smoking, but epidemiological and laboratory
studies support the role of other noxious particles and
gases such as coal dust, silica and particulate matter from
biomass fuels. As the smoke from the cannabis joint
contains a mixture of potentially noxious and injurious
products, it is plausible that smoking cannabis may be
linked to the development of COPD.
The potential for cannabis to be detrimental to lung
health was first noted in studies undertaken in California
when Tashkin and colleagues recruited a convenience
sample of nearly 300 subjects aged 2549 years who
marijuana for at least five years.14 Applying a modified
education
version of the American Thoracic Society/National
Heart, Lung and Blood Institute respiratory questionnaire
they found that the symptoms of acute and chronic
bronchitis were substantially and significantly more
prevalent among marijuana smokers compared with
non-marijuana smokers of a similar age.The results were
not affected by whether an individual smoked, or did not
smoke, tobacco in addition to marijuana.
Later North American studies examined the potential
effects of cannabis smoking in the general population by
investigating subjects enrolled in several large cohort
studies.1517 Bloom and colleagues reported data from a
longitudinal household study from Tucson, Arizona.15 The
seventh survey, undertaken from 1981 to 1983, included
information on the duration and intensity of non-tobacco
(assumed to be marijuana) smoking and the authors
reported that the prevalence of respiratory symptoms
such as phlegm and wheeze was increased in smokers of
non-tobacco cigarettes. As had been observed by Tashkin
and colleagues, the results were not affected by whether
or not the subjects had smoked additional tobacco.
A further study from Tucson reporting respiratory
symptoms and pulmonary function in nearly 2,000
subjects aged 1560 years found that compared with non-
smokers, smokers of non-tobacco cigarettes were almost
two times more likely to report cough, chronic phlegm
and wheeze.16 Symptoms were most prevalent in those
who had smoked for several years and persisted despite
quitting smoking.
The third National Health and Nutrition Examination
Survey (NHANES III) was used to report a much larger
North American general population study in which
329
 PT Reid, J Macleod, JR Robertson
Moore and colleagues were able to include nearly 7,000
adults aged 2059 years.17 The use of marijuana (defined
as self-reported 100+ lifetime use and at least one day
of use in the past month) was accompanied by a variety
of respiratory symptoms, including chronic bronchitis,
coughing on most days, phlegm production, wheezing
and chest sounds without a cold. Those who smoked
both tobacco and marijuana had a greater prevalence of
respiratory symptoms than those who smoked only
tobacco. A potentially important public health message
was that the marijuana users had similar rates of
respiratory symptoms as tobacco users even though
they were ten years younger.
While the data on chronic bronchitis and other respiratory
symptoms appear reasonably consistent between these
different centres, the relationship between smoking
cannabis and lung function remains less clear. In a
longitudinal study of nearly 400 healthy Caucasian adults
who smoked marijuana on a regular basis, Tashkin and
colleagues found no significant adverse effect on lung
function. The subjects in this study were predominantly
men in their early thirties who had consumed an average
of 3.5 joints per day for around five years.18 Although
education
Moore and colleagues reported an initial observation that
marijuana smoking was associated with an obstructive
ventilatory defect, this disappeared when corrected for
other potential confounding factors. However, both of
the Tucson studies have suggested that smoking non-
tobacco cigarettes was associated with airways
obstruction. A more detailed analysis of nearly 900
people studied as part of a population-based study of
obstructive lung disease being undertaken in Vancouver,
Canada, has shown that regular cannabis smokers were
nearly three times more likely than non-smokers to have
COPD as defined by spirometric testing.19
The data from New Zealand, where the other main
body of literature on cannabis emerges, are similar.
Taylor and colleagues selected a group of 20-year-old
cannabis-dependent individuals who had been enrolled
in the Dunedin Multidisciplinary Health and Development
Study.20 After correcting for tobacco use the authors
reported that compared with non-tobacco users,
cannabis dependence was associated with an increased
odds ratio of reporting respiratory symptoms such as
cough and sputum, wheezing apart from colds, exercise-
induced shortness of breath and sputum production,
nocturnal wakening and chest tightness. The frequency
of reported symptoms was similar to subjects who
smoked between one and ten cigarettes per day. Just
over one-third of cannabis-dependent subjects had an
obstructive ventilatory defect compared with around
one-fifth of non-smokers; the outcomes were
independent of co-existing bronchial asthma. A further
longitudinal study from the same authors collected data
at ages 18, 21 and 26.21 For each age an increasing use of
cannabis was associated with a decline in first-second
330
expiratory volume (FEV1)/vital capacity (VC); however,
after controlling for possible confounding factors, only a
marginal effect remained. There was no significant
interaction between cannabis use and cigarette smoking,
which suggested to the authors that cumulative cannabis
use and daily cigarette smoking act in an additive fashion.
Investigators from the Greater W
ellington region reported
data pertaining to symptoms, lung function and the
prevalence of emphysema as measured by high-resolution
computed tomography (CT) scan in a convenience sample
of just over 300 adult subjects.22 Smoking cannabis
(predominantly in the form of joints) was accompanied by
chest tightness, wheeze, cough and chronic bronchitis and
the presence of asthma diagnosed after the age of 16
years. The effects of cannabis smoke and tobacco smoke
were additive. Smoking cannabis was also associated with
a dose-related impairment of airflow obstruction, large
airways function and hyperinflation. The authors estimated
that, for measures of airflow obstruction, one cannabis
joint had a similar effect to 2.55 tobacco cigarettes.
However, while cannabis smoking was associated with
decreased lung density on a high-resolution CT scan, in
contrast to tobacco smoking, macroscopic emphysema
was seldom observed.
Most recently, a population-based cohort study from
Dunedin, New Zealand, has reported the effects of
cannabis on the lung function of just over 1,000 subjects
aged 32 years.23 Cannabis use was associated with higher
lung volumes, hyperinflation and increased large-airways
resistance, but there was little evidence for airflow
obstruction or impairment of gas transfer, as seen with
tobacco smoking. The authors suggested that cannabis
appears to have different effects on lung structure
and function from tobacco and is less likely to result
in emphysema.
These observations, although containing some
contradictions and inconsistency, have contributed to an
emerging concern among respiratory physicians that
regular cannabis smoking may promote the development
of COPD. Nonetheless, it remains uncertain whether
cannabis smoking contributes to the development of
emphysema. The data from New Zealand would suggest
that the occurrence of emphysema is unusual in cannabis
smokers; however, this appears to be frequently observed
by UK chest physicians24 and selected case reports have
published dramatic bullous disease.25,26
Issues of ethnicity aside, one possible explanation for the
apparent differences in the spectrum of pulmonary
disease associated with cannabis use may relate to the
type of cannabis available and the method of smoking. As
mentioned, the most common form of cannabis used in
Scotland is cannabis resin, imported from North Africa,
which is cut with tobacco and smoked as an unfiltered
joint. The resin is often impure, being adulterated with a
J R Coll Physicians Edinb 2010; 40:32834
2010 RCPE

range of other contaminants. In North America, cannabis
is more usually supplied as marijuana, typically imported
from Mexico and, particularly in the earlier studies, the
herbal cannabis available is likely to have been of low
potency compared with that available today. New
Zealand imports very little cannabis, with much of it
being grown wild or at home using hydroponic plants,
and a greater number of users employ bongs. These and
other differences may be important in the pattern
of disease observed and further studies are needed
to investigate the effects of cannabis, given the
potential public health agenda if so many young people
smoke the drug.
Cannabis and Pneumothorax
Selected case reports and small case series have hinted at
an association between pneumothorax and cannabis
smoking.2729 In one series, 13 of 15 consecutive patients
with spontaneous pneumomediastinum or subcutaneous
emphysema admitted to using marijuana extensively
before coming to hospital.30 More recently, Beshay and
colleagues have reported the findings in 17 young regular
marijuana smokers presenting with spontaneous
pneumothorax with bullous emphysema, comparing them
with the findings of non-marijuana smoking patients
presenting during the same 30-month period.31 Computed
tomography imaging of the lungs revealed multiple bullae
at the apex or significant bullous emphysema. Also, in
common with other reports, this dramatic emphysema
occurred largely in the absence of spirometric
abnormalities. Only two patients had reduced FEV1 and
one reduced VC below 50% of predicted. This correlated
with the subjectively asymptomatic condition of the
patients. Histology showed severe lung emphysema,
inflammation and heavily pigmented macrophages.
This pathological description by Beshay and colleagues is
reminiscent of the Australian experience of bong lung. Gill
reviewed the histopathology of ten known cannabis
smokers (although several also used cocaine) who under-
went video-assisted thoracoscopic surgery and resection
of bullae.32 All the marijuana smokers showed features of
irregular emphysema with prominent irregularly dilated
airspaces, cysts, blebs and bullae. In addition, they observed
massive accumulation of intra-alveolar pigmented
histiocytes (smokers macrophages) with a desquamative
interstitial pneumonia (DIP)-like appearance. However, in
contrast to DIP, interstitial scarring and bullous disease
were very prominent and there was no radiographical
evidence of interstitial lung disease. Gill proposed that this
DIP-like pattern with massive accumulation of pigmented
histocytes and pulmonary apical cystic disease may be
strongly suggestive of illegal drug use.
The occurrence of pneumothorax and the descriptions
of bullous lung disease may lend some weight to the
concerns that cannabis smoking is linked to bullous
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Cannabis and the lung
emphysema; however, not all of the subjects reported in
these studies showed evidence of emphysema.
Cannabis and Pulmonary Infections
Cannabis exerts a variety of effects on inflammatory and
immune cells and it seems credible to suggest that, as
with regular tobacco smoking, regular cannabis smoking
may be accompanied by an increased risk of respiratory
infections. Moore and colleagues reported an increased
odds ratio of self-reported pneumonia,17 but none of the
other studies appear to have reported this endpoint.
Smoking tobacco is known to be associated with an
increased risk of developing tuberculosis (TB). To date,
no studies have suggested the same from cannabis
smoking, but there is evidence that the spread of TB may
be facilitated by the shared smoking of cannabis.
Munckhof and colleagues reported a cluster of cases of
TB occurring in young males from Queensland, Australia,
in whom marijuana smoking through bongs was common
among cases and contacts.33 Although the most important
risk factor for acquiring TB was close household contact
with a case, sharing a bong with a case was associated
education
with a more than doubled risk of pulmonary TB.
Variants on the method of cannabis smoking have also
been linked to an increased risk of TB transmission. For
example, hotboxing describes the behaviour of smoking
marijuana inside a car with the windows closed so that
users may repeatedly inhale exhaled smoke. Among
users who reported or were observed hotboxing, the
majority who received a tuberculin skin test had a
positive result. Shotgunning refers to inhaling smoke
from illicit drugs, then exhaling it directly into another
persons mouth. Perhaps not surprisingly, this practice is
associated with a high risk of TB transmission.34
The identification of fungal spores in cannabis plants has
led to suggestions that smoking the drug may increase
the risk of fungal respiratory infections. Pulmonary
aspergillosis as a complication of bone marrow
transplantion for chronic myeloid leukaemia has been
reported in a patient who had smoked marijuana
heavily.35 Cultures of the marijuana used by the individual
revealed Aspergillus fumigatus with morphology and
growth characteristics identical to the organism grown
from open lung biopsy. Similar reports emphasise the
potential importance of smoking cannabis in other
immunosuppressed subjects.36,37
Cannabis and Lung Cancer
The cannabis joint is qualitatively similar in terms of tar
and carcinogen content to a standard cigarette. Several
studies have demonstrated pre-cancerous histological
and molecular abnormalities in the respiratory tracts of
cannabis smokers, and the carcinogenic effects of
331
 PT Reid, J Macleod, JR Robertson
cannabis smoke have been demonstrated in in vitro and
in vivo animal models. However, the problems inherent in
the design and power of clinical studies that would
provide strong evidence of an association between
cannabis smoking and the subsequent development of
lung cancer mean that robust evidence may be some
way off. Nonetheless, the subject is attracting the
attention of researchers. While some studies have failed
to identify such links,38 several smaller studies have reported
an increased risk of developing lung cancer in relation to
smoking cannabis, as hinted at by the basic science.
Investigators from Tunisia reported a hospital-based
case-control study including 149 cases of lung cancer
and 188 controls.39 As expected, tobacco smoking was
significantly associated with an increased risk of lung
cancer, with the greatest risks being seen in those that
smoked the most; however, lung cancer was seen almost
four times more frequently in individuals with past
cannabis use (odds ratio 3.7, 95% confidence interval
[CI] 1.87.5). The association remained statistically
significant after adjustment for age, tobacco smoking and
occupational exposure.
education
A hospital-based case-control study from Casablanca,
Morocco included 118 incident lung cancer cases and
235 age-, sex- and residence-matched controls.40 While
tobacco smoking and a history of chronic bronchitis
were the strongest risk factors for lung cancer the
combined use of hashish/kiff and snuff had an odds ratio
of 6.67 (95% CI: 1.6526.90) and the odds ratio for
hashish/kiff (without snuff) was 1.93 (95% CI: 0.576.58).
A further pooled analysis of three hospital-based case-
control studies in Tunisia, Morocco and Algeria identified
a total of 430 cases and 778 controls (all male).41
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Adjusting for country, age, tobacco smoking and
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association remained after adjustment for lifetime
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SUMMARY
Cannabis is a commonly used illegal drug that is mostly
smoked. Although the potential adverse respiratory
effects have received relatively little attention the studies
that have been reported suggest that habitual smoking of
cannabis may contribute to the development of
COPD, pneumothorax, respiratory infections, including
tuberculosis, and lung cancer.
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SELF-ASSESSMENT QUESTIONS
1. The predominant method of taking cannabis in
the UK is?
A. Eating as hash cakes.
B. Smoking resin with tobacco rolled as a joint.
C. Smoking resin alone without tobacco rolled as a joint.
D. Smoking marijuana with tobacco rolled as a joint.
E. Smoking marijuana without tobacco rolled as a joint.
2. Which one of the following is not true of cannabis?
A. D9THC may act to induce bronchial smooth muscle
relaxation when taken acutely.
B. D9THC binds to naturally occurring receptors in the
brain.
J R Coll Physicians Edinb 2010; 40:32834
2010 RCPE
Cannabis and the lung
30 Mattox KL. Pneumomediastinum in heroin and marijuana users.
JACEP 1976; 5:268. doi:10.1016/S0361-1124(76)80162-1
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pneumothorax in young adults smoking cannabis. Eur J Cardiothorac
Surg 2007; 32:8349. doi:10.1016/j.ejcts.2007.07.039
32 Gill A. Bong lung: regular smokers of cannabis show relatively
distinctive histologic changes that predispose to pneumothorax. Am
J Surg Pathol 2005; 29:9802. doi:10.1097/01.pas.0000157998.68800.cb
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C. The plant grows slowly in a limited range of climatic
conditions.
D. The plant can be difficult to cultivate indoors.
E. The most potent forms of the drug are derived from
female plants.
3. Which of the following is consistently reported in
studies investigating regular cannabis smokers?
A. Symptoms of chronic bronchitis.
B. An accelerated decline in FEV1.
C. The presence of bullous emphysema.
D. A decreased risk of pneumothorax.
E. A decreased risk of lung cancer.
333
 PT Reid, J Macleod, JR Robertson

4. Which of the following has not been reported in 5. Which one of the following statements is accurate?
association with cannabis use?
A. The cannabis smoked in California is similar to that
A. Tuberculosis. smoked in Scotland.
B. Pneumomediastinum. B. Cannabis resin is a predominantly pure drug.
C. Fungal lung infection. C. Pneumothorax has not been described in persons
D. Pneumonia. smoking cannabis through bongs.
E. Pulmonary carcinoid. D. The risk of contracting tuberculosis may be increased
by hotboxing.
E. The use of skunk is declining.

For the answers, please turn to page 382.

Invitation to submit papers

We would like to extend an invitation to all readers of The Journal of the Royal
College of Physicians of Edinburgh to contribute original material, especially to the
clinical section. The JRCPE is a peer-reviewed journal with a circulation of 8,000. Its
aim is to publish a range of clinical, educational and historical material of cross-
specialty interest to the Colleges international membership.

The JRCPE has recently been accepted for Medline indexing and is also currently
education

indexed in Embase, Google Scholar and the Directory of Open Access Journals.
The editorial team is keen to continue to improve both the quality of content
and its relevance to clinical practice for Fellows and Members. All papers are
subject to peer review and our turnaround time for a decision averages only
eight weeks.

We would be pleased to consider submissions based on original clinical research,

including pilot studies. The JRCPE is a particularly good forum for research performed by junior doctors under
consultant supervision. We would also consider clinical audits where the loop has been closed and a demonstrable
clinical benefit has resulted.

For further information about submissions, please visit: http://www.rcpe.ac.uk/journal/contributers.php

or e-mail editorial@rcpe.ac.uk. Thank you for your interest in the Colleges journal.
The editorial team,
The Journal of the Royal College of Physicians of Edinburgh

334 J R Coll Physicians Edinb 2010; 40:32834

2010 RCPE